State of California Health and Human Services Agency Department of Health Care Services Every applicant or provider must complete and submit a current Medi-Cal Disclosure Statement (DHCS 6207) as part of a complete application package for enrollment, continued enrollment, or certification as a Medi-Cal provider. Important: · FOR NEW APPLICANTS: Failure to disclose complete and accurate information may result in a denial of enrollment and imposition of a three-year reapplication bar. · FOR CURRENTLY ENROLLED APPLICANTS: Failure to disclose complete and accurate information may result in denial, deactivation of all business addresses and the imposition of a three-year reapplication bar. The Department is required to report the termination of your participation in the MediCal Program to the Centers for Medicare & Medicaid Services and to other States' Medicaid and Children's Health Insurance Programs pursuant to United States Code, Title 42, Sections 1396a(kk)(6) and 1902(kk)(6) and the Code of Federal Regulations, Title 42, Section 1002.3(b). · · · · · Submitting a complete and accurate Medi-Cal Disclosure Statement is required. Read all instructions when completing the Medi-Cal Disclosure Statement. Type or print clearly in ink. DO NOT USE staples on this form or on any attachments. If applicant/provider must make corrections, please line through, date, and initial in ink. Do not use correction fluid. · Return this completed statement with the complete application package to the address listed on the application form. Overall Authority: Code of Federal Regulations, Title 42, Part 455; California Code of Regulations, Title 22, Sections 51000­51451; Welfare and Institutions Code, Sections 14043­14043.75 DHCS 6207 (Rev. 2/17) American LegalNet, Inc. www.FormsWorkFlow.com State of California Health and Human Services Agency Department of Health Care Services TABLE OF CONTENTS GENERAL INSTRUCTIONS .................................................................................................... I. II. III. IV. V. VI. VII. VIII. APPLICANT/PROVIDER INFORMATION .............................................................................. UNINCORPORATED SOLE-PROPRIETOR OR INDIVIDUAL RENDERING PROVIDER ADDING TO A GROUP .......................................................................................................... OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION (ENTITIES) .... ii 1 5 6 OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION (INDIVIDUALS) 9 SUBCONTRACTOR INFORMATION AND SIGNIFICANT BUSINESS TRANSACTIONS ..... INCONTINENCE SUPPLIES ................................................................................................... PHARMACY APPLICANTS OR PROVIDERS ........................................................................ DECLARATION AND SIGNATURE PAGE ............................................................................ 13 18 19 20 DHCS 6207 (Rev. 2/17) i American LegalNet, Inc. www.FormsWorkFlow.com State of California Health and Human Services Agency Department of Health Care Services GENERAL INSTRUCTIONS FOR COMPLETING THE MEDI-CAL DISCLOSURE STATEMENT · · · · · DO NOT USE staples on this form or on any attachments. Do not use a pencil, correction tape, white out, highlighter pen, etc. on this form. If you must correct an entry, the applicant or provider must initial and date the correction in ink. Do not leave any questions, boxes, lines, etc., blank. Check or write "N/A" if not applicable to you. To review the Title 22 provider enrollment regulations, please visit the Medi-Cal Website (www.medi-cal.ca.gov) and click the "Provider Enrollment" link. It is the responsibility of the applicant/provider to comply with all regulations pertaining to Medi-Cal. Section I: Applicant/Provider Information 1. All applicants and providers must complete this Section unless they are eligible to use the "Medi-Cal Rendering Provider Application/Disclosure Statement/Agreement for Physician/Allied/Dental Providers" (DHCS 6216) or the "Medi-Cal Ordering/Referring/Prescribing Provider Application/Agreement/ Disclosure Statement for Physician and Nonphysician Practitioners" (DHCS 6219). 2. Rendering providers joining a group who are not eligible to use the "Medi-Cal Rendering Provider Application/Disclosure Statement/Agreement for Physician/Allied/Dental Providers" may leave parts E­H blank if part D is checked. 3. If applicant leases the location where services are being rendered or provided, please attach a copy of a current signed lease agreement. 4. In California, a domestic or foreign limited liability company is not permitted to render professional services, as defined in Corporations Code Sections 13401, subdivision (a) and 13401.3. See California Corporations Code Section 17701.04(e). Section II: Unincorporated Sole-Proprietor or Individual Rendering Provider Adding to a Group Disclosure of social security number is optional. (See Privacy Statement on page 21) Section III: Ownership Interest and/or Managing Control Information (Entities) 1. To determine percentage of ownership, mortgage, deed of trust, note or other obligation, the percentage of interest owned in the obligation is multiplied by the percentage of the disclosing entity's assets used to secure the obligation. For example, if A owns 10 percent of a note secured by 60 percent of the applicant's or provider's assets, A's interest in the provider's assets equates to 6 percent and shall be reported pursuant to California Code of Regulations, Title 22, Section 51000.35. Conversely, if B owns 40 percent of a note secured by 10 percent of the applicant's or provider's assets, B's interest in the provider's assets equates to 4 percent and need not be reported. 2. "Indirect ownership interest" means an ownership interest in any entity that has an ownership interest in the applicant or provider. This term includes an ownership interest in any entity that has an indirect ownership interest in the applicant or provider. The amount of indirect ownership interest is determined by multiplying the percentages of ownership in each entity. For example, if A owns 10 percent of the stock in a corporation which owns 80 percent of the stock of the applicant or provider, A's interest equates to an 8 percent indirect ownership interest in the applicant or provider and shall be reported pursuant to California Code of Regulations, Title 22, Section 51000.35. Conversely, if B owns 80 percent of the stock of